Open vs robotic gastrectomy with D2 lymphadenectomy: a propensity score-matched analysis on 1469 patients from the IMIGASTRIC prospective database.

BACKGROUND: Comparative data on D2-robotic gastrectomy (RG) vs D2-open gastrectomy (OG) are lacking in the Literature. Aim of this paper is to compare RG to OG with a focus on D2-lymphadenectomy. STUDY DESIGN: Data of patients undergoing D2-OG or RG for gastric cancer were retrieved from the international IMIGASTRIC prospective database and compared. RESULTS: A total of 1469 patients were selected for inclusion in the study. After 1:1 propensity score matching, a total of 580 patients were matched and included in the final analysis, 290 in each group, RG vs OG. RG had longer operation time (210 vs 330 min, p < 0.0001), reduced intraoperative blood loss (155 vs 119.7 ml, p < 0.0001), time to liquid diet (4.4 vs 3 days, p < 0.0001) and to peristalsis (2.4 vs 2 days, p < 0.0001), and length of postoperative stay (11 vs 8 days, p < 0.0001). Morbidity rate was higher in OG (24.1% vs 16.2%, p = 0.017). CONCLUSION: RG significantly expedites recovery and reduces the risk of complications compared to OG. However, long-term survival is similar.

Resolution of drug-resistant hypertension by adrenal vein sampling-guided adrenalectomy: a proof-of-concept study.

Drug-resistant hypertension (RH) is a very high-risk condition involving many hypertensive patients, in whom primary aldosteronism (PA) is commonly overlooked. Hence, we aimed at determining if (1) adrenal vein sampling (AVS) can identify PA in RH patients, who are challenging because of receiving multiple interfering drugs; (2) AVS-guided adrenalectomy can resolve high blood pressure (BP) resistance to treatment in these patients. Based on a pilot study we selected from 1016 consecutive patients referred to our Centre for 'difficult-to-treat' hypertension those with RH, for an observational prospective cohort study. We excluded those non-adherent to treatment (by therapeutic drug monitoring) and those with pseudo-RH (by 24-h BP monitoring), which left 110 patients who met the European Society of Cardiology/European Society of Hypertension (ESC/ESH) 2013 definition for RH. Of these patients, 77 were submitted to AVS, who showed unilateral PA in 27 (mean age 55 years; male/female 19/8). Therefore, these patients underwent AVS-guided laparoscopic unilateral adrenalectomy, which resolved RH in all: 20% were clinically cured in that they no longer needed any antihypertensive treatment; 96% were biochemically cured. Systolic and diastolic BP fell from 165/100 ± 26/14 mmHg at baseline, to 132/84 ± 14/9 mmHg at 6 months after surgery (P<10-4 for both) notwithstanding the fall of number and defined daily dose (DDD) of antihypertensive drugs required to achieve BP control (P<10-4 for both). A prominent regression of cardiac and renal damage was also observed. Thus, the present study shows the feasibility of identifying PA by AVS in RH patients, and of resolving high BP resistance to treatment in these patients by AVS-guided adrenalectomy.

Cardiovascular predictors of death in patients with cirrhosis.

Cirrhotic cardiomyopathy is associated with poor outcomes in patients with cirrhosis. We investigated if subclinical cardiac morphologic and functional modifications can influence survival in patients with cirrhosis during follow-up. A series of patients with cirrhosis without cardiovascular or pulmonary disease underwent standard and tissue Doppler echocardiography to assess left ventricular geometry, systolic/diastolic function, and the main haemodynamic parameters. After baseline evaluation 115 patients with cirrhosis were followed up for at least 6 years. During follow-up 54 patients died (47%). On univariate analysis, age, body surface area (BSA), Model for End-Stage Liver Disease (MELD), mean arterial pressure, heart rate, cardiac index, systemic vascular resistance index, and the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/è) were associated with increased risk of death. In a Cox hazard regression analysis including these factors and other hypothesized important factors (but not MELD), increased age (P = 0.04) and left atrial dimension (P = 0.005) and lower BSA (P = 0.03) were the strongest predictors of death. When MELD was included in the analysis, the main predictors were MELD, age, and BSA. When multivariate analysis was performed incorporating only cardiovascular parameters, increased E/è (P = 0.003) and heart rate (P = 0.03) and reduced mean blood pressure (P = 0.01) were significantly associated with poor prognosis. CONCLUSION: In a large cohort of patients with cirrhosis and after a long follow-up, MELD, age, and BSA were the main predictors of death; among cardiovascular parameters, left atrium enlargement, increased heart rate and E/è, and reduced mean blood pressure were independent predictors of death. (Hepatology 2018).

Arterial Hypertension, Aldosterone, and Atrial Fibrillation.

PURPOSE: Atrial fibrillation is the most common sustained arrhythmia, with a prevalence of 1-2% in the general population and over 15% in people older than 80 years. Due to aging of the population it imposes an increasing burden on the healthcare system because of the need for life-long pharmacological treatment and the associated increased risk of heart failure and hospitalization. Hence, identification of the factors that predispose to atrial fibrillation it is of utmost relevance. RECENT FINDINGS: Several conditions exist that are characterized by inappropriately high levels of aldosterone, mostly primary aldosteronism and the severe or drug-resistant forms of arterial hypertension. In these forms, aldosterone can cause prominent target organ damage, mostly in the heart, vasculature, and kidney. This review examines the experimental data and clinical evidences that support a link between hyperaldosteronism and atrial fibrillation, and how this knowledge should lead to a change in our management of the hypertensive patients presenting with atrial fibrillation.

A sleep apnoea questionnaire predicts organ damage in hypertensive patients.

BACKGROUND: Arterial hypertension is associated with obstructive sleep apnoea, poor quality and duration of sleep, which might contribute to hypertension-mediated organ damage. METHODS: We investigated the presence of insomnia, restless legs syndrome, and obstructive sleep apnoea using validated questionnaires (Insomnia Severity Index, Restless Legs Syndrome Rating Scale, and STOP-Bang), and their relationship with hypertension-mediated organ damage, in hypertensive patients. RESULTS: In 159 consecutive consenting hypertensive patients [age 47(11) years, median and (interquartile range), body mass index 25.5(5.9) kg/m2, office systolic and diastolic blood pressure 144(23)/92(12) mmHg], the STOP-Bang, but not the other scores, predicted cardiac remodelling: compared to patients with a STOP-Bang score < 3, those at high risk of obstructive sleep apnoea showed higher left ventricular mass index [49.8(11.9) vs. 43.3(11.9) g/m2.7, p < 0.0001], left atrium volume [25.7(2.5) vs. 25.0(2.8) ml/m2, p = 0.003], and aortic root diameter [33.6(3.0) vs. 33.0(3.7) mm, p < 0.0001]. They did not differ for microalbuminuria and estimated glomerular filtration rate. At multivariate analysis, after adjustment for office systolic blood pressure values, the STOP-Bang score remained a predictor of left ventricular mass index; while the Insomnia Severity Index and restless legs syndrome risk score had no predictive value. However, a significant interaction between STOP-Bang and Restless Legs Syndrome Rating Scale scores in determining left ventricular remodelling was found. CONCLUSIONS: In consecutive hypertensive stage I patients the STOP-Bang questionnaire allowed identification of a high-risk cohort featuring a more prominent cardiac damage. Hence, this inexpensive tool can be useful for risk stratification purposes in municipalities with limited access to health care resources.

Macrolides for KCNJ5-mutated aldosterone-producing adenoma (MAPA): design of a study for personalized diagnosis of primary aldosteronism.

PURPOSE: Aldosterone-producing adenoma (APA) is the main curable cause of endocrine hypertension cause of primary aldosteronism (PA) and it is in up to 66% of all cases investigated with adrenal vein sampling (AVS). Mutations in the KCNJ5 potassium channel involve up to 70% of APA and cause the most florid PA phenotypes. The recent finding that macrolide antibiotics specifically inhibit in vitro the altered function of mutated KCNJ5 channels has opened new horizons for the diagnosis and treatment of APA with KCNJ5 mutations in that it can allow identification and target treatment of PA patients harbouring a mutated APA. Thus, we aimed at investigating if clarithromycin and roxithromycin, two macrolides that potently blunt mutated Kir3.4 channel function in vitro, affect plasma aldosterone concentration in adrenal vein blood during AVS and in peripheral blood, respectively, in PA patients with a mutated APA. METHODS AND DESIGN: We designed two proof of concept studies. In study A: consecutive patients with an unambiguous biochemical evidence of PA will be exposed to a single dose of 250 mg clarithromycin during AVS, to assess its effect on the relative aldosterone secretion index in adrenal vein blood from the gland with and without APA. In study B: consecutive hypertensive patients submitted to the work-up for hypertension will receive a single oral dose of 150 mg roxithromycin. The experimental endpoints will be the change induced by roxithromycin of plasma aldosterone concentration and other steroids, direct active renin concentration, serum K+, systolic and diastolic blood pressure. DISCUSSION: We expect to prove that: (i) clarithromycin allows identification of mutated APA before adrenalectomy and sequencing of tumour DNA; (ii) the acute changes of plasma aldosterone concentration, direct active renin concentration, and blood pressure in peripheral venous blood after roxithromycin can be a proxy for the presence of an APA with somatic mutations.

Galectin-3 predicts long-term cardiovascular death in high-risk patients with coronary artery disease.

OBJECTIVE: Galectin-3 (Gal-3) can affect atherogenesis by multiple mechanisms, but it remains scarcely known whether plasma Gal-3 levels predict cardiovascular events in patients with coronary artery disease. Therefore, we investigated if Gal-3 predicts cardiovascular death in patients with coronary artery disease of the Genetic and ENvironmental factors In Coronary Artery disease study. APPROACH AND RESULTS: In a prospective cohort study, we measured the plasma levels of Gal-3 in 1013 randomly selected patients who underwent coronary angiography and long-term follow-up to assess incident cardiovascular events. The primary end points were (1) cardiovascular death and (2) a composite of cardiovascular death, acute coronary syndrome, and stroke. Secondary end points entailed (1) acute myocardial infarction, (2) stroke, and (3) a composite fatal ischemic event including fatal myocardial infarction and stroke. The effect of Gal-3 on prognosis was assessed using Kaplan-Meier analysis and multivariate Cox's regression. During long-term follow-up (median, 7.2 years), 115 cardiovascular deaths occurred (15.2%), more commonly in the high Gal-3 tertile (25.2%) than in the intermediate and the low tertiles (13.6% versus 7.5%, respectively; P<0.001). The adverse prognostic effect of high Gal-3 was confirmed in subgroup analysis of the patients with angiographically documented coronary artery disease and also of those with a normal left ventricular ejection fraction. At multivariate analysis, Gal-3 was a predictor of cardiovascular mortality (hazard ratio, 1.79; 95% confidence interval, 1.10-2.93; P=0.020) along with age, left ventricular ejection fraction, and coronary atherosclerotic burden. CONCLUSIONS: In high cardiovascular risk patients referred for coronary angiography Gal-3 is a strong independent predictor of cardiovascular death.

Laparoscopic treatment for ventral hernia in obese patients.

AIM: Obese patients generally are not considered good candidates for wall defect repair, because of associated comorbidities, increased surgical risk, and high risk of surgical site infection and recurrence. The purpose of this retrospective study was to evaluate the results of laparoscopic incisional hernia repair in a group of patients with Body Mass Index (BMI)>35 kg/m2. MATERIAL AND METHOD: From January 2016 to October 2018, 15 obese patients, including 11 females (73.3%) with a BMI > 35 kg/m2 underwent laparoscopic repair of an incisional abdominal hernia. Median BMI was 40 (SD±5). No selection related to comorbidities was performed. As primary endpoints, main postoperative general complications and hernia recurrence were taken into account. Secondary endpoints were the incidence of seroma, hematoma, wound infection and length of hospitalization. In addition, a systematic review of the literature on open and laparoscopic repair techniques was carried out. RESULTS: All patients were treated by laparoscopy and no conversions were required. No intraoperative complications were observed, and no patients underwent early re-intervention. Mortality was zero. One patient (6.6%) presented a seroma, conservatively managed, and evaluated over time without the need of re-intervention. One patient (6.6%) suffered a recurrence a year later, also treated by laparoscopy. Average hospital stay was 2.79 days (DS±0.77). CONCLUSIONS: Despite positive data and good results, laparoscopic treatment of wall defects has yet to be standardized. The feasibility of the laparoscopy for ventral hernias in patients with BMI>35 kg/m2 should be considered. The proposed technique is standardizable and easily reproducible. In terms of complications in the short term (perforations, kidney and pulmonary failure, cardiovascular events) and in the long term (relapses, wound infections, seromas) our results justify recommendation of the minimally invasive approach for almost all patients with abdominal wall defects. KEY WORDS: Laparoscopy, Obese, Ventral hernia.

Laparoscopic mechanical latero-lateral esophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results.

BACKGROUND: The realization of an esophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We report our laparoscopic experience in intracorporeal esophagojejunostomy. METHODS: Adults who underwent laparoscopic total gastrectomy for cancer with latero-lateral (functional termino-terminal) Roux en Y intracorporeal esophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra- and postoperative outcomes including 30-day readmissions and mortality were considered. RESULTS: Thirty-two patients were included. Nodal dissection D1 was 16. Median operative time was 280'. Median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent nonoperative management. Median postoperative stay was 8.5 days. CONCLUSIONS: This technique may improve the ergonomics of esophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

Exon 11 deletion in the myocyte enhancer factor (MEF)2A and early onset coronary artery disease gene in a Sicilian family.

AIMS: We investigated the prevalence of the myocyte enhancer factor (MEF)2A exon 11 deletion, a putative coronary artery disease (CAD) susceptibility gene, in patients referred for coronary angiography. METHODS AND RESULTS: In total, 1079 consecutive patients referred for coronary angiography in the GENICA Study were genotyped and 301 low-risk subjects were used as controls. One patient with early onset three vessels CAD, carrying the MEF2A deletion was found in the GENICA Study cohort and none in the control group. CONCLUSION: In a cohort of patients undergoing coronary angiography for suspected CAD the MEF2A exon 11 deletion occurred in 0.09%.

Prevalence and prognostic value of cirrhotic cardiomyopathy as defined according to the proposed new classification.

AIM OF THE STUDY: Prevalence and prognostic relevance of cirrhotic cardiomyopathy (CCM), as defined according to the new core criteria proposed in 2019, are still unknown. We investigated this relevant issue in a large cohort of cirrhotic patients. MATERIAL AND METHODS: We retrospectively interrogated a data set of 162 collected cirrhotic patients followed up for at least 6 years, who underwent standard Doppler echocardiography and were compared with 46 healthy subjects. Left ventricular (LV) geometry, systo-diastolic function, global longitudinal strain and the main hemodynamic parameters were assessed according to current guidelines. Systolic dysfunction was diagnosed if LV ejection fraction (LVEF) ≤ 50% and/or global longitudinal strain (GLS) < 18% or > 22%. RESULTS: Adequate echocardiographic images permitting speckle tracking analysis were available in 83 patients. No patient presented LVEF ≤ 50%, GLS < 18% or > 22% was evident in 25%, advanced diastolic dysfunction was evident in 10%. Overall the prevalence of CCM was 29%. Patients with and without CCM presented similar clinical, biochemical, hemodynamic and echocardiographic features at baseline and similar incidence of death or type 1 hepatorenal syndrome at follow-up. CONCLUSIONS: According to the new criteria CCM is detected in 29%, mainly due to altered GLS at rest, but without prognostic relevance and therefore useless for the clinical management of cirrhotic patients. We propose to modify the criteria by removing the LVEF assessment and adding also a stress test assessing the cardiac contractile reserve to distinguish patients with a blunted cardiac response, which could present a worst prognosis.

Low myocardial mechano-energetic efficiency is an independent predictor of prognosis in advanced chronic liver disease.

OBJECTIVE: We aimed at investigating if a low myocardial mechano-energetic efficiency (MEE) with energy waste could be a feature of cirrhotic cardiomyopathy and predictive of poor prognosis. METHODS: We retrospectively interrogated a large data set of 115 cirrhotic patients followed up for 6 years and compared with 50 healthy controls. Echocardiographic and haemodynamic parameters were assessed at baseline according with current guidelines. MEE was estimated by echocardiographic stroke volume (z-derived)/(heart rate × 0.6). RESULTS: Cirrhotic patients presented low peripheral vascular resistance, a compensatory hyperdynamic syndrome with increased cardiac work, left atrial and left ventricular (LV) dimension and mass. Systolic parameters and MEE were similar between patients and controls. Patients with cirrhosis and refractory ascites showed significantly lower MEE compared with both patients with treatable ascites and patients without ascites (1.68 ± 0.47 vs. 1.98 ± 0.64 and 1.80 ± 0.37 ml/s; P < 0.05). Increased age and heart rate and reduced body weight, cardiac dimension and work significantly correlated with lower MEE, mostly when compared nonalcoholic with alcoholic cirrhosis (1.65 ± 0.42 vs. 1.95 ± 0.56 ml/s respectively; P = 0.002). Among the cardiovascular parameters left atrium enlargement and reduced MEE were independent predictors of death. CONCLUSIONS: In advanced chronic liver disease left ventricular performance is blunted due to an energetically inefficient cardiac mechanical work which correlates with a poor prognosis. Therefore, the simple basal assessment of MEE can identify patients with a worst prognosis which requires a close follow-up.

The cardiovascular consequences of hyperaldosteronism.

Primary aldosteronism (PA), the most common form of secondary hypertension, has been considered for decades as a "benign" form of hypertension, but evidences progressively built up to show that patients with PA had an excess rate of cardiovascular damage as compared to blood pressure-matched essential hypertensive patients. This review provides an updated view of structural and electrical cardiac remodeling and of vascular changes in hyperaldosteronism, and how they can favor development of cardiovascular events. The link between hyperaldosteronism and resistant hypertension is also examined, and the impact of targeted treatment of hyperaldosteronism on cardiovascular changes is finally discussed.

High sodium intake, glomerular hyperfiltration, and protein catabolism in patients with essential hypertension.

AIMS: A blood pressure (BP)-independent metabolic shift towards a catabolic state upon high sodium (Na+) diet, ultimately favouring body fluid preservation, has recently been described in pre-clinical controlled settings. We sought to investigate the real-life impact of high Na+ intake on measures of renal Na+/water handling and metabolic signatures, as surrogates for cardiovascular risk, in hypertensive patients. METHODS AND RESULTS: We analysed clinical and biochemical data from 766 consecutive patients with essential hypertension, collected at the time of screening for secondary causes. The systematic screening protocol included 24 h urine (24 h-u-) collection on usual diet and avoidance of renin-angiotensin-aldosterone system-confounding medications. Urinary 24 h-Na+ excretion, used to define classes of Na+ intake (low ≤2.3 g/day; medium 2.3-5 g/day; high >5 g/day), was an independent predictor of glomerular filtration rate after correction for age, sex, BP, BMI, aldosterone, and potassium excretion [P = 0.001; low: 94.1 (69.9-118.8) vs. high: 127.5 (108.3-147.8) mL/min/1.73 m2]. Renal Na+ and water handling diverged, with higher fractional excretion of Na+ and lower fractional excretion of water in those with evidence of high Na+ intake [FENa: low 0.39% (0.30-0.47) vs. high 0.81% (0.73-0.98), P < 0.001; FEwater: low 1.13% (0.73-1.72) vs. high 0.89% (0.69-1.12), P = 0.015]. Despite higher FENa, these patients showed higher absolute 24 h Na+ reabsorption and higher associated tubular energy expenditure, estimated by tubular Na+/ATP stoichiometry, accordingly [Δhigh-low = 18 (12-24) kcal/day, P < 0.001]. At non-targeted liquid chromatography/mass spectrometry plasma metabolomics in an unselected subcohort (n = 67), metabolites which were more abundant in high versus low Na+ intake (P < 0.05) mostly entailed intermediates or end products of protein catabolism/urea cycle. CONCLUSION: When exposed to high Na+ intake, kidneys dissociate Na+ and water handling. In hypertensive patients, this comes at the cost of higher glomerular filtration rate, increased tubular energy expenditure, and protein catabolism from endogenous (muscle) or excess exogenous (dietary) sources. Glomerular hyperfiltration and the metabolic shift may have broad implications on global cardiovascular risk independent of BP.

Laparoscopic Compared with Open D2 Gastrectomy on Perioperative and Long-Term, Stage-Stratified Oncological Outcomes for Gastric Cancer: A Propensity Score-Matched Analysis of the IMIGASTRIC Database.

BACKGROUND: The laparoscopic approach in gastric cancer surgery is being increasingly adopted worldwide. However, studies focusing specifically on laparoscopic gastrectomy with D2 lymphadenectomy are still lacking in the literature. This retrospective study aimed to compare the short-term and long-term outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy for gastric cancer. METHODS: The protocol-based, international IMIGASTRIC (International study group on Minimally Invasive surgery for Gastric Cancer) registry was queried to retrieve data on patients undergoing laparoscopic or open gastrectomy with D2 lymphadenectomy for gastric cancer with curative intent from January 2000 to December 2014. Eleven predefined, demographical, clinical, and pathological variables were used to conduct a 1:1 propensity score matching (PSM) analysis to investigate intraoperative and recovery outcomes, complications, pathological findings, and survival data between the two groups. Predictive factors of long-term survival were also assessed. RESULTS: A total of 3033 patients from 14 participating institutions were selected from the IMIGASTRIC database. After 1:1 PSM, a total of 1248 patients, 624 in the laparoscopic group and 624 in the open group, were matched and included in the final analysis. The total operative time (median 180 versus 240 min, p < 0.0001) and the length of the postoperative hospital stay (median 10 versus 14.8 days, p < 0.0001) were longer in the open group than in the laparoscopic group. The conversion to open rate was 1.9%. The proportion of patients with in-hospital complications was higher in the open group (21.3% versus 15.1%, p = 0.004). The median number of harvested lymph nodes was higher in the laparoscopic approach (median 32 versus 28, p < 0.0001), and the proportion of positive resection margins was higher (p = 0.021) in the open group (5.9%) than in the laparoscopic group (3.2%). There was no significant difference between the groups in five-year overall survival rates (77.4% laparoscopic versus 75.2% open, p = 0.229). CONCLUSION: The adoption of the laparoscopic approach for gastric resection with D2 lymphadenectomy shortened the length of hospital stay and reduced postoperative complications with respect to the open approach. The five-year overall survival rate after laparoscopy was comparable to that for patients who underwent open D2 resection. The types of surgical approaches are not independent predictive factors for five-year overall survival.

A kidney tumor in an adolescent with severe hypertension and hypokalemia: an uncommon case--case report and review of the literature on reninoma.

This report presents a case of a 16-year-old hypertensive boy who presented to our clinic. Laboratory findings showed severe hypokalemia and markedly increased plasma renin activity. Abdominal ultrasonography and contrast-enhanced computed tomography of the abdomen revealed a well-circumscribed, solid, hypoenhancing cortical lesion (2 cm) in the lower pole of the left kidney. The patient underwent nephron-sparing surgery. Histopathologic examination gave a diagnosis of juxtaglomerular cell tumor. Reninoma is an uncommon cause of hypertension in a young adult and should be included in the differential diagnosis as a potential life-threatening and curable condition. The conservative surgical management is the gold standard for small, circumscribed lesions.

Primary aldosteronism in elderly, old, and very old patients.

Primary aldosteronism (PA) is common, but usually overlooked in the elderly, old, and very old patients in whom the already high absolute risk of cardiovascular events, particularly atrial fibrillation, can be further increased by PA. Although in the last two decades there has been an explosion of studies devoted to diagnosis, subtyping, and treatment of PA, only relatively scant investigation has addressed these topics in patients older than 65 years of age. This narrative review fills a gap of information on the challenges of diagnosing and managing the PA patients who are 65 years old and older with particular attention to the benefit/risk ratio of pursuing the diagnosis in this cohort, which is markedly expanding owing to ageing of the population worldwide.

Disease monitoring of Primary Aldosteronism.

Primary aldosteronism (PA) is a highly prevalent cause of arterial hypertension featuring excess cardiovascular events. A timely diagnosis and treatment of PA cures hyperaldosteronism and can provide resolution or improvement of arterial hypertension, even when the latter is resistant to drug treatment. Accordingly, strategies to screen early and widely the hypertensive patients for PA by means of simplified diagnostic algorithms are justified. Such strategies are particularly beneficial in subgroups of hypertensive patients, who are at the highest cardiovascular risk. Broadening of screening strategies means facing with an increased number of patients where monitoring the disease becomes necessary. Hence, after identification of the surgically and non surgically curable cases of PA and implementation of targeted treatment physicians are faced with the challenges of follow-up, which are scantly discussed in the literature. Hence, the purpose of this paper is to provide some recommendations on how to optimize the monitoring of patients in whom the PA subtype has been diagnosed and treatment, either with unilateral laparoscopic adrenalectomy or medically, has been instituted.

Effects of Mineralocorticoid and AT1 Receptor Antagonism on The Aldosterone-Renin Ratio In Primary Aldosteronism-the EMIRA Study.

CONTEXT: While current guidelines recommend the withdrawal of mineralocorticoid receptor antagonist (MRA) and renin-angiotensin system blockers for the screening and detection of primary aldosteronism (PA), this can worsen hypokalemia and control of high blood pressure (BP) values. OBJECTIVE: To investigate whether aldosterone/renin ratio (ARR) values were affected by the MRA canrenone and/or by canrenone plus olmesartan treatment in patients with PA. DESIGN: Within-patient study. SETTING: The European Society of Hypertension center of excellence at the University of Padua. PATIENTS: Consecutive patients with an unambiguous diagnosis of PA subtyped by adrenal vein sampling. INTERVENTIONS: Patients were treated for 1 month with canrenone (50-100 mg orally), and for an additional month with canrenone plus olmesartan (10-20 mg orally). Canrenone and olmesartan were up-titrated over the first 2 weeks until BP values and hypokalemia were controlled. Patients with unilateral PA were adrenalectomized; those with bilateral PA were treated medically. MAIN OUTCOME MEASURES: BP, plasma levels of sodium and potassium, renin and aldosterone. RESULTS: Canrenone neither lowered plasma aldosterone nor increased renin; thus, the high ARR and true positive rate remained unaffected. Addition of the angiotensin type 1 receptor blocker raised renin and slightly lowered aldosterone, which reduced the ARR and increased the false negative rate. CONCLUSIONS: At doses that effectively controlled serum potassium and BP values, canrenone did not preclude an accurate diagnosis in patients with PA. Addition of the angiotensin type 1 receptor blocker olmesartan slightly raised the false negative rate. Hence, MRA did not seem to endanger the accuracy of the diagnosis of PA.